Individual
MICHAEL KEITH BURNSIDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPC, LADC
Contact information
Practice address
100 W 7TH ST STE 102, OKMULGEE, OK 74447-5007
(918) 758-1910
(918) 756-1270
Mailing address
720 S 5TH ST, MORRIS, OK 74445-2224
(918) 733-4603
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
553
OK
101YP2500X
Professional Counselor
Primary
2650
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
300522336
MEDICARE
OK
Enumeration date
07/27/2006
Last updated
03/13/2009
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